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SERVICE DELIVERY SYSTEM OF MENTAL HEALTH IN

INDIABY:

DR. ROBIN VICTORPGT, DEPT. OF PSYCHIATRY

SMCH

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PLAN OF PRESENTATION INTRODUCTION PREVIOUS VEIWPOINT ON MENTAL HEALTH NATIONAL MENTAL HEALTH PROGRAMME DISTRICT MENTAL HEALTH PROGRAM SCHOOL MENTAL HEALTH PROGRAM ROLE OF NGO’S PERSON WITH DISABILITY ACT 1995 PRIORITIES FOR FUTURE BIBLIOGRAPHY

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INTRODUCTION It is estimated that 7-10% of population of

world suffers from mental disorders. The World Bank report (1993) revealed that the

Disability Adjusted Life Year (DALY) loss due to neuropsychiatric disorder is much higher than diarrhea, malaria, worm infestations and tuberculosis if taken individually.

One in four families is likely to have at least one member with a behavioral or mental disorder (WHO 2001).

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EXISTING SERVICES IN INDIA AND PREVALENCE OF MENTAL DISORDERS 70 million mentally ill in the Country of 1.25 billion population 20,000 beds in 42 mental hospitals. Point prevalence- 10 to 20/1000 population are affected by serious

mental disorder. MANPOWER AVAILABLE IN INDIAPsychiatrists (qualified) in India = ~4000 Per 100,000 population = 0.2 (World = 1.2) Total qualified doctors in India =9.36 lacsClinical psychologists in India =~1000 Per 100,000 population = 0.03 (World = 0.6)Psychiatric social workers = ~1000 Per 100,000 population = 0.03 (World = 0.4)

Source: Atlas: Mental Health Resources in the World, 2010, WHO

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PREVIOUS VEIWPOINT ON MENTAL HEALTH

INDIAN LUNANCY ACT was passed in Pre independence times in the year 1912 and terms like “lunatic”,”criminal lunatic”,”asylum” etc were used in this act.

The BHORE Committee Report (1946) It laid the foundation for the community health movement in

India, not only combined the ‘top down’ and the ‘bottoms up’ approaches but also included substantive emphasis on issues of mental health but within the limitations of that period, much before some of the noted western movements of community mental health.

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The MUDALIAR Committee report (1959) It assumed the population of mental health patients 2/1000 Shortage of mental health professionals. Recommended inclusion of preventive mental services as well

(school counselling, orientation of public professionals). Recommended need for increased research.

The SRIVASTAVA Committee report(1974) It recommended establishment of 3 cadres of health workers

namely – multipurpose health workers, health assistants between the community level workers and doctors at PHC.

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NATIONAL MENTAL HEALTH PROGRAMME Mental health is a state of wellbeing characterized by the

absence of mental or behaviour disorder whereby the person has made a satisfactory adjustment as an individual, and to the community, in relation to emotional, personal, social and spiritual aspects of there life”- K PARK

According to WHO:“Mental health has been defined as a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment.”

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FACTORS WHICH CONTRIBUTED TO THE DRAFTING OF THE NATIONAL MENTAL HEALTH PROGRAMME FOR INDIA DURING THE EARLY 1980’s1. The organization of mental health services in developing

countries” – a set of recommendations by an expert committee of the World Health Organization.

2. Starting of a specially designated “Community Mental Health Unit” at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore – 1975.

3. World Health Organization (WHO) Multi-country project: “Strategies for extending mental health services into the community” (1976-1981)

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4. The “Declaration of Alma Ata”- to achieve “Health for All by 2000” by universal provision of primary health care (1978) .

5. Indian Council of Medical Research – Department of Science and Technology (ICMR-DST) Collaborative project on ‘Severe Mental Morbidity’

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STARTING OF A SPECIALLY DESIGNATED “COMMUNITY MENTAL HEALTH UNIT” AT NIMHANS, BANGALORE – 1975 Mental health needs assessment and situation analysis at Rural

mental health center at Sakalwara in Bangalore rural district covering a population of about 100,000.

Simple methods of identification and management of persons with mentally illness by primary care personnel.

Pilot training programs in basic mental health care for primary health care (PHC) personnel were conducted

Draft manuals of instructions written & pilot tested. CMHU at NIMHANS developed a strategy for taking mental health

care to the rural areas through the existing primary health care network

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WHO MULTI-COUNTRY PROJECT: “STRATEGIES FOR EXTENDING MENTAL HEALTH SERVICES INTO THE COMMUNITY” (1976-1981) Model of integrating mental health with general health

services and providing basic mental health care by trained health workers and doctors, supported by Multi-country collaborative project initiated by the WHO and carried out in 7 geographically defined areas in 7 developing countries.

The department of psychiatry (PGIMER)in Chandigarh was the centre in India and the model was developed in the Raipur Rani block in Haryana state.

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DECLARATION OF ALMA ATA(U.S.S.R-1978)Concept of primary health care was defined as “Essential health care based on practical,

scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of the development in the spirit of self determination”

India is a signatory to the Alma Ata declaration of 1978.The national health policy, approved by the parliament in 1983 clearly indicates India’s commitment to the goal of “Health for All by the Year 2000 AD”

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INDIAN COUNCIL OF MEDICAL RESEARCH – DEPARTMENT OF SCIENCE AND TECHNOLOGY (ICMR-DST) COLLABORATIVE PROJECT ON ‘SEVERE MENTAL MORBIDITY’ During the late 1970s and the early 1980s, ICMR and the

Department of science and Technology (DST) ,Government of India funded a 4 center collaborative study to evaluate the feasibility of training PHC staff to provide mental health care as part of their routine work.

Evaluation was carried out for 1 year covering a population of 40,000 in a PHC at four centres, one each from the South, North, East and West of the country, Bangalore, Patiala, Calcutta and Baroda

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At the end of one year period about 20% of the actual cases of mental illness were identified and managed by the PHC personnel under the overall supervision of the centre staff.

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BIRTH OF NATIONAL MENTAL HEALTH PROGRAMExpert group was formed in 1980

A Draft copy of the program was prepared by February,1981 at Lucknow

Draft was discussed in July,1981 at a national level workshop

Revised draft program incorporating some of the points from the previous workshop was made.

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A larger workshop in a/w experts from psychiatry, other medical specialties, education ,administration ,law and social welfare was held in august,1981

The program document was then prepared and then submitted to the central council of health,1982

After detailed evaluation of the document the council adopted a resolution to implement it across states and union territories

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OBJECTIVES OF NMHP (1982)

1. To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population.

2. To encourage the application of mental health knowledge in general healthcare and in social development

3. To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.

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STRATEGIES

1. Integration of mental health with primary health care through the NMHP.

2. Provision of tertiary care institutions for treatment of mental disorders.

3. Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority and State Mental health Authority.

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GOALS OF NMHP (1982) WITHIN ONE YEAR:1. Each state will have adopted the present plan.2. Government of India will have appointed a focal point

within the ministry of health specifically for Mental Health action.

3. National coordinating group will be formed comprising representatives of each state, senior health administrators, professionals from psychiatry, social welfare and education.

4. Task force will have worked out outlines curriculum of mental health workers and for MO’s at PHC level.

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WITHIN FIVE YEAR:1. 5000 of target non-medical professionals will have

undergone 2 weeks training in mental healthcare.2. 20% of all Physicians working in PHC will have gone 2

week training programme in mental health.

Creation of a post of psychiatrist in at least 50% of districts. Psychiatrist at the district level will visit all the PHC’s

regularly at least once a month for supervision and education. This is to be fully operational in at least one district in every states and UT and in at least half of all districts in some states within 5 years.

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Each state will appoint a program officer responsible for organization and supervision of mental health program

Each state will provide additional support for incorporating common mental health components in teaching curricula

On recommendation of the task force appropriate psychotropic drugs to be made essential drugs and available at PHC level

Psychiatric units with in-patient facility will be made available in all medical college hospitals in the country

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PROGRESS OF NMHP BETWEEN 1982-2002

ICMR launched a mental morbidity demonstration project that examined the feasibility and effectiveness of the above approach in four centers namely- Kolkata, Baroda, Bangalore and Patiala.

In 1984 district model for mental health care was initiated at NIMHANS, Bangalore in collaboration with the district administration and the director of health service, Karnataka which showed the possibility of improving mental health care at PHC level.

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This same model was adopted along with the District Mental Health Program (DMHP) and was implemented to 25 districts in 20 states between 1995-2000.

A wide variety of community care alternatives have come to light specially from voluntary sectors. These include day care centers, half way homes, long-stay homes, suicide prevention program and school mental health program.

It was anticipated that in the 10th five year plan this would be extended to 100 districts.

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At the time of formulation of the NMHP, the number of psychiatrist were less than 1000. In these 20 years it had nearly tripled to 3000.

There was an increase in the public awareness enormously due to community based mental health care, initiatives of the voluntary health organization, trained mental health professionals working in remote areas in private sector and availability of the modern mental health information to the general pubic via these professionals.

Many legislations were passed related to mental health namely: NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCE ACT (NDPS)1985. MENTAL HEALTH ACT 1987. PEOPLE WITH DISABILITY ACT 1995.

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Revision of the National Health Policy in 2002.In 1983 the NHP had not referred to mental health in any significant manner. This was redressed in the revision of the NHP in 2002 which clearly recognized mental health as apart of general health and importance of human rights of mentally ill. Growth of the mass media in 20 years.Television and radio stations were available in many languages which addressed mental health issues through phone in program, serials, features, movies, panel discussion and audio participation programs.

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STRENGTHS

1. Proposed mutually synergistic integration of mental health care with primary health care

2. Proposed to use Primary Health Centre machinery 3. Integration of all aspects of teaching, research and

therapeutics.

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WEAKNESSES

1. Emphasis on curative rather than promotive or preventive aspects of mental health.

2. Community resources like family was not given due importance.

3. No clear cut model for macro implementation.

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BARRIERS TO THE IMPLEMENTATION OF NMHP Limited undergraduate training in psychiatry. Inadequate mental health human resources. Lack of policy driven epidemiological data and research

driven mental healthcare policies. Limited number of models and their evaluation. Uneven distribution of resources across states. Non-implementation of the MHA, 1987. Privatization of healthcare in the 1990s.

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HOW EFFECTIVE IS THE IMPLEMENTATION OF NMHP? Most reports suggest that the implementation is far from

optimal and the reasons are numerous A variety of lacunae in the current implementation of NMHP

have been reported. These include: 1. Absence of full time programme officer for NMHP in many

states2. Inadequacies in the training for PHC personnel.3. Inadequate record maintenance. 4. Non-availability of basic information about patients

undergoing treatment at various centres (regularity of treatment, outcome of treatment, drop-out rates etc)

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5. Difficulties in recruitment and retention of mental health professionals in the DMHP

6. Non-involvement of the NGOs and the private sector. 7. Inadequate mental health educational and community awareness

activities absence of programme outcome indicators and monitoring

8. Inadequate technical support from mental health experts.9. As the NMHP primarily focuses on rural areas, the need for

decentralized mental health care in urban areas has been highlighted.

10.While funding itself has not been a problem, delayed receipt of funds, irregular dispersal of funds, administrative blocks in the full utilization of available funds and a variety managerial issues have bogged down the proper implementation of the NMHP in many states and Union Territories.

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REVISED GOALS FOR THE MENTAL HEALTH PROGRAMME Redesigning DMHP around a nodal institution. Strengthening medical colleges to develop manpower,

secondary facilities, encourage general hospital psychiatry.

Modernization of mental hospitals. Strengthening of state mental health authorities. Research and training on epidemiology, course/outcome,

needs, cost effective intervention models.

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Strengthening families and communities for the care of persons suffering from mental disorders.

Organization of a wide range of mental health initiatives to support individuals and families.

Special focus on immediate delivery of the most essential services to the ones with the greatest needs.

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DISTRICT MENTAL HEALTH PROGRAM (DMHP)

In 1996 the Ministry Of Health and Family Welfare, Govt. Of India formulated District Mental Health Program (under national mental health program) as a fully centrally funded program.

DMHP was launched in four districts in 1996 and later extended to 27 districts in 22 States/UTs during the Ninth plan with a total outlay of Rs. 28 crore.

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Launched in 1996–97 in four districts, one each in Andhra Pradesh, Assam, Rajasthan, and Tamil Nadu

At present the program is in place in 127 districts DMHP is also being started in 325 new districts The central grant for implementation of DMHP per district

with average population of 20 lakh for five years will be Rs. 2.5 crore.

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BIRTH OF DMHP 1982-1990 – Development of the pilot district mental

health programme at “Bellary district” in Karnataka by NIMHANS.

The successful implementation and outcome of this programme led to formulation of the DMHP

Bellary district : population of about 20 lakhs located about 350 kms. away from Bangalore chosen for the pilot development of a (DMHP).

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COMPONENTS OF THE BELLARY PROGRAM

Training for all primary care staff. Provision of 6 essential psychotropic and anti epileptic drugs

(chlorpromazine, amitryptaline, trihexyphenidyl, injection fluphenazine deaconate, phenobarbitone and diphenyl hydantoin) at all PHCs and sub-centres,

A system of simple mental heath case records. A system of monthly reporting. Regular monitoring and feed back from the district level mental

health team.

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Mental health clinic at the district hospital to review patients referred from the PHCs.

Admit up to 10 patients at the district hospital for brief in patient treatment.

The mental health programme was reviewed every month at the district level by the district health officer during the monthly meeting of primary health centre medical officers.

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OBJECTIVES OF DISTRICT MENTAL HEALTH PROGRAM1. To provide sustainable mental health services to the

community and to integrate these services with other services.

2. Early detection and treatment of patients within the community itself.

3. To see that patient and their relatives do not have to travel long distances to go to hospitals or nursing homes in cities.

4. To take pressure off mental hospitals.5. To reduce the stigma attached towards mental illness

through change of attitude and public education.6. To treat and rehabilitate mentally ill patients discharged

from the mental hospital within the community.

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COMPONENTS OF SERVICES PROVIDED BY DMHP(REVISED IN 11th FIVE YEAR PLAN)

Personnel:The team of workers at the district under the program consists of: Psychiatrist. Clinical or trained psychologist. Trained social worker. Trained nurses or psychiatric nurses. Statistician-cum-clerk. Program Manager. Program/Case Registry Assistant. Record Keeper.

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Equipment, vehicles and other infrastructure Medicines & other contingencies etc IEC components: Use of print, electronic media, conducting

health mela’s etc. Training programme for various workers such as nurses,

social workers, non- proffesionals like panchayat leaders, ANM’s, teachers, Anganwadi workers among others in identified institutions.

Development of training capsules for various workers and their translation in regional languages .Work done in NIMHANS, Bangalore and CIP, Ranchi in this direction was taken in to consideration.

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Currently DMHP is being implemented in 127 districts in the country.

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There are three districts which have/are receiving 100% central assistance for District Mental Health Program (DMHP) under National Mental Health Program. This scheme is for a period of 5 years, after which the state has to takeover the scheme.

These districts are as given below:- SL. NO DISTRICT NODAL INSTITUTE

YEAR OF IMPLEMENTATION

REMARKS

1 Muktsar GMC, Amritsar

2003 Completed 5 years on 31.3.2008

2 Hoshiarpur GMC, Amritsar

2007 -

3 Sangrur GMC, Amritsar

2007 -

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2002 TO 2007 - X FIVE YEAR PLAN PERIOD

The NMHP was re-strategized in the year 2003 (in X Five Year Plan) with the following components: 1. Extension of DMHP to 100 districts. 2. Up gradation of Psychiatry wings of Government

Medical Colleges/ General Hospitals .3. Modernization of State Mental hospitals. 4. IEC. 5. Monitoring & Evaluation.

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UP GRADATION OF PSYCHIATRIC WINGS OF MEDICAL COLLEGES/GENERAL HOSPITALS Every medical college should ideally have a Department of

Psychiatry with: Minimum of three faculty members and In-patient facilities of about 30 beds as per the norms laid

down by the MCI Scheme for strengthening of the psychiatric wings of

government medical colleges/hospitals which provides for a one-time grant of Rs.50 lakhs for up gradation of infrastructure and equipment as per the existing norms.

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Aim of the scheme was to strengthen the training facilities for UG & PG at Psychiatry wings of government medical colleges/hospitals.

Grant covers construction of new ward, repair of existing ward, procurement of items like cots, tables and equipments for psychiatric use such as modified ECTs.

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MODERNIZATION OF STATE RUN MENTAL HOSPITALS

The assistance under this scheme is provided for modernization of state run mental hospitals from custodial care to comprehensive management.

A one-time grant with a ceiling of Rs.3.00 crores per hospital is provided.

The grant covers activities such as: Construction/repair of existing building(s), Purchase of cots and equipment's. Provision of infrastructure such as water- tanks and toilet

facilities etc.

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Does not cover recurring expenses towards running the mental hospitals and cost towards drugs and consumables.

Grant is for modernization of the mental hospitals only and any increase in the number of beds in the hospital is not permitted.

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Effectiveness of DMHP

An audit of DMHP carried out by NIMHANS in 2003 in the 27 districts where the program was started during 1996-2002 showed that there were numerous problems and bottlenecks in the actual implementation of DMHP.

The efficiency and the effectiveness of the program varied widely between districts and states / union territories.

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Factors attributed to the differential effectiveness include:1. Motivation and commitment of the nodal officer and the

programme staff2. Interest and administrative support of the state health

authorities (which include senior officers of Directorate of Health Services, Directorate of Medical Education, Principal of Medical College, Head of the District Hospital etc.)

3. Absence of an effective Central Support and Monitoring mechanism at the Government of India level.

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The audit highlighted the need to : Develop an operational manual for the DMHP. Review the content, curriculum and method of training the

PHC personnel. Provide continued support, supervision and on-the-job

training for PHC personnel after the initial training. Review the priority conditions covered by the DMHP and

make necessary amendments to include common mental disorders.

Enhance IEC activities. Monitor the program regularly and develop time bound

targets. Incorporate aspects prevention and promotion of mental

health such as life skills training and counseling in schools.

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2007-2012 XI FIVE YEAR PLAN

Revised goal setting for District Mental Health Programme (DMHP).

Manpower Development Schemes - Center Of Excellence And Setting Up/ Strengthening PG Training Departments of Mental Health Specialities.

Training & Research Monitoring & Evaluation

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MANPOWER DEVELOPMENT SCHEMES Manpower Development Schemes – Center of Excellence

and Setting Up/ Strengthening PG Training Departments of Mental Health Specialities are the new schemes/components.

It has two schemes which are as follows:

A. Centers of Excellence (Scheme A) B. Setting Up/ Strengthening PG Training Departments of

Mental Health Specialities (Scheme B)

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CENTRES OF EXCELLENCE (SCHEME A) At least 11 Centres of Excellence in mental health were

to be established in the XIth plan period by upgrading existing mental health institutions/hospitals.

A grant of up to Rs.30 crores is available for each centre. The commitment to take over the entire funding of the

scheme after the 11th five year plan period from the state government is required.

The proposal of the State Governments for these centres must include definite plan with timelines for initiating/ increasing PG courses in Psychiatry, Clinical Psychology, PSW and Psychiatric Nursing.

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SETTING UP/ STRENGTHENING PG TRAINING DEPARTMENTS OF MENTAL HEALTH SPECIALITIES (SCHEME B)

To provide further impetus to manpower development in Mental Health, Government Medical Colleges/ Hospitals are supported to start PG courses in Mental Health.

To increase the intake capacity for PG training in Mental Health. The support involves capital work for: Establishing/improving mental health departments (Psychiatry, Clinical

Psychology, Psychiatric Social Work, and Psychiatric Nursing), Equipment's, tools and basic infrastructure, Support for engaging required/deficient faculty for starting/enhancing

the PG courses. The support of up to Rs. 51 lacs to Rs.1 crore per PG department is

available.

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Based on the evaluation conducted by ICMR in 2008 and feedback received from a series of consultations DMHP has now incorporated promotive & preventive activities for positive mental health which includes:

SCHOOL MENTAL HEALTH SERVICE COLLEGE COUNSELING SERVICES: through trained

teachers/ counselors WORK PLACE STRESS MANAGEMENT: formal & informal

sector, including farmers, women etc. SUICIDE PREVENTION SERVICES: Counseling center at

district level, sensitization workshops, IEC, helpline

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SCHOOL MENTAL HEALTH PROGRAM In 2010, this program has been sanctioned to be

implemented in all DMHP districts in the country. AIMS AND OBJECTIVES: Provide Class Teachers with Knowledge and Skills to

Identify Emotional, Conduct Problems in their students

Provide Class Teachers with a system of referral for students with psychological problems to the District Mental Health Team for inputs and treatment.

Provide Class Teachers with Facilitative Skills to Promote Life Skills among their Students.

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The life skills which need to be taught at the school level especially to adolescent as are:

Critical thinking & creative thinking. Decision making & problem solving. Communication skills & interpersonal relations. Coping with emotion & stress. Self awareness & empathy.

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URBAN MENTAL HEALTH CARE– Use of existing public health care infrastructure such

as Municipality hospitals/ Corporation hospital/ other Specialty hospitals, Mental hospitals and Medical college hospitals

– Volunteers and extensive networking with NGOs and other agencies

– Additional facilities like community based detoxification centers; self help groups, halfway homes, day care centers, long stay facilities, respite care centers, crisis intervention centers and counseling services

– Sate home for women, state home for person with mental handicap and the prisoners.

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ROLE OF NGO IN NMHP

Information, Education and Communication activities. Support for health promotion using life skill approach. Support for follow up of severely mentally ill persons in

community. Support for mentally retarded children & their families. Organization of mental health camps. Networking with primary health care team. Facilitation of disability welfare benefits for the mentally ill

& mentally challenged. Home care for severely mentally ill person.

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2012 ONWARDS-XII FIVE YEAR PLAN1. Strengthening of the public sector health care.2. Health sector expenditure by the Centre and States,

to be substantially increased by the end of the Twelfth Plan. It has already increased from 0.94 per cent of GDP in the Tenth Plan to 1.04 per cent in the Eleventh Plan.

3. Efforts would be made to find a workable way of encouraging cooperation between the public and private sector in achieving health goals.

4. Availability of skilled human resources remains a key constraint in expanding health service delivery.

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5. National level tertiary care institutions A single Central Sector Scheme on ‘National Level Tertiary Care

Institutions’ will fund up-gradation of existing medical colleges and converting tertiary care facilities of the Central Government across different departments into teaching institutions.

More AIIMS like Institutions (ALIs) will be established during the Twelfth Plan period in addition to the eight already approved.

The existing teaching institutions will be strengthened to provide leadership in research and practice on different medical conditions, and research themes. Priorities include Cancer, Child Health, Diabetes, Mental Health and Neuro Sciences, Geriatrics,, Information Technology and Tele- Medicine and Complementary Medicine.

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A new category of mid-level health-workers named Community Health Officers, could be developed for primary health care. These workers would be trained after Class XII for a three year period to become competent to provide essential preventive and primary care and implement public health.

6. Information technology in health7. Drug regulation8. Regulation of medical practice Provisions for registration and regulation of clinical

establishments would be implemented effectively; all clinical establishments would also be networked on the Health Information System, and mandated to share data on nationally required parameters

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9. AIDS control There has been a reduction of new HIV infections in the

country by 57 percent. Still, an estimated 20.9 lakh people were living with

HIV/AIDS (PLHA) in 2011. The programme includes Targeted Interventions focused

on High Risk Groups and Bridge populations, Link Workers Scheme, Integrated Counselling and Testing Services, Community Care, Support and Treatment Centres, Information, Education, and Communication (IEC) and condom promotion

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PERSON WITH DISABILITY ACT 1995 Persons with disabilities act,1995 was passed by Loksabha

in 12th dec.1995 and come into enforcement on feb.7,1996.

This act is extends to the whole of India except the state of Jammu and Kashmir.

This act explain the equal opportunities, protection of right and complete involvement of disabled persons.

In this act responsibilities are assigned to central and state government, local corporation and municipalities to provide the services and facilities and equal opportunities to disabled persons so that he/she may also prove himself as productive citizen of there society

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AIMS AND OBJECTIVES

To spell out the responsibility of the state towards the prevention of disabilities, protection of rights, provision of medical care, education, training, employment and rehabilitation of persons with disabilities.

To create a barrier free environment. To counteract any situation of abuse and exploitation of

persons. To make special provision of the integration of persons

with disabilities into the social mainstream.

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MAIN PROVISIONS OF THE ACT

Prevention and early detection of disability Education Employment Non- discrimination Research and manpower development Affirmative action Social security

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PREVENTION AND EARLY DETECTION OF DISABILITY Undertake surveys, investigations and research concerning

the cause of occurrence of disabilities. Promote various methods of preventing disabilities Provide facilities for training to the staff at the primary health

center Take measures for pre-natal and post-natal care of mother

and child Educate the public through the pre-schools, schools, primary

health centers, village level workers and anganwadi workers Create awareness amongst the masses through television,

radio and other mass media on the causes

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EDUCATIONGovernments and the local authorities shall: Ensure that every child with a disability has access to free

education in an appropriate environment till he attains the age of eighteen years;

Endeavour to promote the integration of students with disabilities in the normal schools;

Promote setting up of special schools in Government and private sector for those in need of special education, in such a manner that children with disabilities living in any part of the country have access to such schools;

Endeavour to equip the special schools for children with disabilities with vocational training facilities.

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Conducting part-time classes in respect of children with disabilities who having completed education up to class fifth and could not continue their studies on a whole-time basis;

Conducting special part-time classes for providing functional literacy for children in the age group of sixteen and above;

Imparting non-formal education by utilizing the available manpower in rural areas after giving them appropriate orientation;

Imparting education through open schools or open universities;

Conducting class and discussions through interactive electronic or other media;

Providing every child with disability free of cost special books and equipments needed for his education.

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EMPLOYMENT

Governments shall - a. identify posts, in the establishments, which can be

reserved for the persons with disability; b. at periodical intervals not exceeding three years,

review the list of posts identified and up-date the list taking into consideration the developments in technology.

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NON-DISCRIMINATION Government shall take special measures to-

Adapt rail compartments, buses, vessels and aircrafts in such a way as to permit easy access to such persons;

Adapt toilets in rail compartments, vessels, aircrafts and waiting rooms in such a way as to permit the wheel chair users to use them conveniently.

Installation of auditory signals at red lights in the public roads for the benefit of persons with visual handicap.

Causing curb cuts and slopes to be made in pavements for the easy access of wheel chair users.

Engraving on the surface of the zebra crossing for the blind or for persons with low vision.

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AFFIRMATIVE ACTION The appropriate Governments shall by notification make

schemes to provide aids and appliances to persons with disabilities.

The appropriate Governments and local authorities shall by notification frame schemes in favour of persons with disabilities, for the preferential allotment of land at concessional rates for -

a. house; b. setting up business; c. setting up of special recreation centres; d. establishment of special schools; e. establishment of research centres; f. establishment of factories by entrepreneurs with disabilities.

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"PERSON WITH DISABILITY" means a person suffering from not less than forty per cent of any disability as certified by a medical authority;

CURRENTLY FOLLOWING ARE INCLUDED IN DISABILITY CATEGORY: Blindness Leprosy-cured Hearing impairment; Locomotor disability; Mental retardation; Mental illness

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"BLINDNESS" refers to a condition where a person suffers from any of the following conditions, namely:- 1. Total absence of sight; or 2. Visual acuity not exceeding 6/60 or 20/200 (snellen) in the

better eye with correcting lenses; or 3. Limitation of the field of vision subtending an angle of 20

degree or worse

"PERSON WITH LOW VISION" means a person with impairment of visual functioning even after treatment or standard refractive correction but who uses or is potentially capable of using vision for the planning or execution of a task with appropriate assistive device.

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"HEARING IMPAIRMENT" means loss of sixty decibels or more in the better ear in the conversational range of frequencies; "LEPROSY CURED PERSON" means any person who has been cured of leprosy but is suffering from - i. loss of sensation in hands or feet as well as loss of sensation

and paresis in the eye and eye-lid but with no manifest deformity;

ii. manifest deformity and paresis but having sufficient mobility in their hands and feet to enable them to engage in normal economic activity;

iii. extreme physical deformity as well as advanced age which prevents him from undertaking any gainful occupation, and the expression "leprosy cured" shall be construed accordingly.

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"LOCOMOTOR DISABILITY" means disability of the bones, joints or muscles leading to substantial restriction of the movement of the limbs or any form of cerebral palsy.

"MENTAL ILLNESS" means any mental disorder other than mental retardation.

"MENTAL RETARDATION" means a condition of arrested or incomplete development of mind of a person which is specially characterized by sub-normality of intelligence.

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CERTIFICATIONS PROCESS FOR MENTAL RETARDATION A disability certificate shall be issued by a Medical Board

consisting of three members duly constituted by the Central/State Government.

At least, one shall be a Specialist in the area of mental retardation, namely Psychiatrist, Pediatrician and Clinical Psychologist. The examination process will consist of three components,

namely, clinical assessment, assessment of adaptive behaviour and intellectual functioning.

Categories of mental retardation based on IQ level:a. MILD : 50-69b. MODERATE : 35-49c. SEVERE :20-34d. PROFOUND :<20

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CERTIFICATIONS PROCESS FOR MENTAL ILLNESSThe Center and state Committee has recommended that certification of disability for the purposes of the Act may be carried out by a Medical Board comprising of the following members - THE MEDICAL SUPERINTENDENT/PRINCIPAL/DIRECTOR /HEAD OF

THE CHAIRPERSON INSTITUTION OR HIS NOMINEE PSYCHIATRIST MEMBER PHYSICIAN MEMBER Indian Disability Evaluation and Assessment Scale

(IDEAS) is a scale for measuring and quantifying disability in mental disorders.

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Different types of mental health condition which can lead to a disability, include: Dementia Depression Bipolar disorder Obsessive compulsive disorder Schizophrenia Self-harm.

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There is a need to give special focus on the requirement of persons with disabilities especially for Cerebral Palsy, Autism and Mental Retardation.

For this purpose, the National Trust for the welfare of persons with Autism, cerebral palsy, mental retardation and multiple disabilities should emphasize on prevention, early detection, treatment and rehabilitation of the target groups in its programmes.

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IN THE TWELFTH PLAN EFFORTS ARE DIRECTED : To provide needed support and assistance Rehabilitation

Centres for treating mentally ill persons. Model multi-disability independent living Centre. Provisioning accessibility in State Government institutions. Making State Governments’ websites accessible. Preparation of comprehensive database and online State

depository of resources on disabilities. Establishment of State Missions and District Coordinators. Awareness generation and publicity training of care-givers. Establishment of National Institute of Mental Health

Rehabilitation.

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Establishment of State Disability Resource Centres. Establishment of Micro-enterprises Incubation Centres for

persons with disabilities. Grant of Association for Rehabilitation Under National

Trust Initiative of Marketing (ARUNIM) for supporting its marketing activities.

Research on disability related technology, products and issues.

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PRIORITIES FOR FUTURE Approach of NMHP should be adapted to changing need

with strategies such as openness, continuous evaluation, learning from the experiences.

The nature of mental health requires that actions and interventions be multidimensional, involving a number of sectors, professionals, approaches.

There is wide variations across the states of India, plans should be developed for each of the states and union territories, besides the national plan and program.

All the Psychiatric care institutions should be upgraded with trained personnel, treatment and rehabilitation facilities, community outreach activities.

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All the medical colleges should have independent Departments of Psychiatry to ensure UG & PG training in Psychiatry

Setting up of District and Sub-district Mental Health Team for adequate surveillance and monitoring of activities.

Support from the government for the families of the mentally ill persons in terms of community based services, financial support for care, formation of self help groups, involvement in future planning.

Psychotropic drugs including 2nd generation antipsychotics and antidepressants to be made essential and freely available.

Enhanced involvement and aid to voluntary agencies to take more wide initiatives.

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Planned mental health manpower development by increasing the centers of training and creating opportunities for employment.

Community mental health facilities such as day care centers, half way and long stay homes.

Emphasis on public mental health education through all available traditional and modern media.

To understand the prevalence, nature, course, treatment response and the impact of social changes and developmental policies, researches at the National, regional and local level should be supported.

National level institutions to evaluate the models of care, training of different categories of personnel and monitoring the mental health programmes

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The advances in the understanding of human behavior and mental disorders justify the optimism of developing meaningful and realistic mental health programmes.

It is mandatory to bring the fruits of science to the total population of India.

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BIBLIOGRAPHY

MENTAL HEALTH- AN INDIAN PERSPECTIVE :S P AGGARWAL

A SHORT TEXTBOOK OF PSYCHIATRY :NEERAJ AHUJA PARK’S TEXTBOOK OF PREVENTIVE & SOCIAL

MEDICINE: 22ND ED WWW.MOHFW.NIC.IN WWW.NCBI.NLM.NIH.GOV

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